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Leveraging Analytics to Change Opioid Prescribing Behavior
Session BP3, February 11, 2019
Mark Binstock, MD, MPH; CMIO Bon Secours Mercy Health
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Mark Binstock, MD, MPH
Has no real or apparent conflicts of interest to report.
Conflict of Interest
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Analytics
Prevention
Screening
Treatment
Agenda
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Explore the key metrics for opioid prescribing
Confirm the central role of morphine equivalents in opioid
analytics
Review key provider facing tools to reduce inappropriate opioid
prescribing
Emphasize the contributions of People and Process to success
Learning Objectives
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Mercy Health earns HIMSS Davies
Award for innovative approach to
opioid fight.’
“The Ohio health system implemented analytics and
decision support to reduce opioid prescriptions.”
- HealthcareIT News
https://www.healthcareitnews.com/news/mercy-health-earns-himss-davies-award-innovative-approach-
opioid-fight
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CDC National Guidelines: A Foundation for Our
Build and Analytics
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https://www.cdc.gov/drugoverdose/prescribing/guideline.html
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Outpatient Opioid Prescribing
Data Summary
-12%
-16%
-30%
-15
-50%
-20%
Significant Reductions in Opioid Prescribing Metrics
The following opioid ordering behaviors were substantially reduced
between December 2018 and December 2018:
Total Opioid
Orders
Opioid Orders to
All Medication
Orders
Opioids Orders
w/ MEDD > 80
Opioids w/ Day
Supply > 7 days
Total MEDD
per pt
Opioids
Orders w/
MEDD >30
Acute Pain
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Morphine Equivalents
The key to opioid analytics:
Analogy of calories to food
Method of quantifying any opioid order
(prescription)
Morphine Equivalent Daily Dose (MEDD):
Potency (conversion factor) X Dose (milligrams)
X Frequency per day
Can also be used at an order, patient, ordering
provider, specialty, regional and population level:
Potency X Dose X Dispense quantity
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Analytics Methodologies - Core
Opioid Metrics
Total Opioid Orders: Raw count of narcotic orders within reporting period
Auth Provider Outlier: Indicates that on any of the 3 Sentinel metrics the
provider scores BELOW the 10th percentile
Avg Percentile for 3 Sentinel Metrics: Mean of the Percentiles of the 3
Sentinel metrics
Total MEQ RX: Cumulative morphine equivalent burden for all narcotics
ordered within reporting period. gold standard takes into consideration
potency, dose, frequency, and quantity dispensed
Percentile Auth Provider Total MEQ RX: This represents the percentile score
of the provider compared with peers with lower percentiles (in red shades)
being associated with higher MEQ and higher percentiles (in green shades)
associated with lower MEQ
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Analytics Methodologies - Core
Opioid Metrics
Rate MEQD GT30 to Acute Opioid Orders: The proportion among narcotic
orders placed for acute pain episodes where the morphine equivalent daily
dose exceeded 30
Percentile Auth Provider Rate MEQD GT 30 to Acute Opioid Orders:
Percentile score of the provider compared with peers with lower percentiles
(in red shades) associated with higher MEQD >30 and higher percentiles (in
green shades) associated with lower MEQD>30
Rate MEQD GT 80 to opioid orders: Proportion of all narcotic orders where
the morphine equivalent daily dose exceeded 80
Percentile Auth Provider Rate MEQD GT 80 to Opioid Orders: Percentile
score of the provider compared with peers with lower percentiles (in red
shades) associated with higher MEQD>80 and higher percentiles (in green
shades) associated with lower MEQD>80
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Two Opioid Key Performance
Indicators for 2018
1) Morphine Equivalent daily dose limit for acute pain
prescriptions
Numerator: Number of total outpatient mode prescriptions where
morphine equivalent dose per day greater than 30
Denominator: Acute outpatient opioid orders (in patients with no prior
opiate prescriptions in the last 100 days)
2) Opiate Burden
Numerator: Total opiate burden (morphine equivalents)
Denominator: Total unique patients with one or more selected
encounters
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Region Baseline and Targets:
Two metrics:
1. Rate MEDD > 30 to Acute Opioid Orders
2. Opioid Burden Rate
2018 targets are 90% of 2017 baseline
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Users Guide to Opiate Data Cube
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Performance on Metrics by Region
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MEDD>30 for Acute Prescriptions
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Opioid Burden
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(Total MEDD for opioid prescriptions to number of unique patients)
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Rate Morphine Equivalents >30
(Opioid naïve patients, Ohio law
8.31.17)
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Opioid Burden: Total Morphine
equivalent divided by patient
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2018 Opioid Prescribing Metrics by
Month
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*Red box = Two strategic initiatives
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Provider Dashboard
(Over time with drill down to orders)
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Provider-level Graphs
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Medication Assisted Therapy (MAT)
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Prevention: Provider-Facing Tools
to Reduce Opioid Prescribing
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State Level Responses to the
Opioid Crisis
August 31, 2017 (Ohio)
“7/5/30”
No more than 7 days of opioids can be prescribed for adults and 5 days of opioids can be
prescribed for minors & only after the written consent of parent/guardian
The total MEDD of a prescription for acute pain cannot exceed 30
Rules apply to the first opioid analgesic prescription for the treatment of an episode of acute
pain
November 15, 2017 (Kentucky)
Limit of 3 day supply on C-II for acute pain
December 29, 2017 (Ohio)
Require diagnosis association on all opioid prescriptions
Require indication of days supply on all controlled substance and gabapentin
prescriptions
June 1, 2018 (Ohio)
Require diagnosis association on all controlled substances
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Preference List Customization
Creation via import of opioid specific facility preference list
containing fully configured compliant orders for selected common
acute opioids.
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Preference List Customization
Providers can use either fully configured orders or select a less
configured choice.
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In-Line MEDD Calculation
All opioid containing medications possess a visual indicator of the calculated
MEDD within the order composer
Dynamically calculates based on order dose and frequency
Does not calculate
with free-text sigs
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MEDD Calculation
Calculated Morphine Equivalent Daily Dose (MEDD)
Have added a hyperlink in the upper right corner of our
Prescription Monitoring navigator section
Cannot calculate with free-text sigs
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Day Supply Limitations
Day Supply Designation
Hard Stop
Number of days will be dynamically
appended to sig when using discrete sigs
(default)
Issue: Long-term meds, PRN frequency,
dispense qty, and duration may not always
align
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Order Validation Alerts: MEDD
Threshold of 80 MEDD
c
c
Threshold of 30 MEDD
Order Validations fire at the END of the ordering workflow
Content ONLY provides stage directions for what is
suggested but no follow up actions via the popup
If providers select “Accept” the order is placed
***Both MEDD and Days Supply can fire simultaneously
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Order Validation: Days Supply
Ohio Adolescent: Days Supply = 5
Kentucky Patient: Days Supply = 3
c
Ohio Adult: Days Supply = 7
c
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Unsigned Order BPA: MEDD
Threshold of 80 MEDD
c
c
Threshold of 30 MEDD
Unsigned Order BPA fires at the BEGINNING of the ordering workflow.
It provides follow up actions such as removing orders, placing Naloxone prescription, and
links to document flowsheet values.
If providers select “Accept” the order is NOT placed
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Unsigned Order BPA: Days Supply
Ohio Adolescent: Days Supply = 5
Kentucky Patient: Days Supply = 3
c
Ohio Adult: Days Supply = 7
c
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Controlled Substance Monitoring
SmartForm, Phase I
As a result of 2015 Ohio legislation, a SmartForm was implemented into Mercy’s EHR for quick
documentation that could be utilized for reports.
Provided attestation button to document within the EMR that the PDMP report was reviewed -
a compliance requirement from PDMP
Any documentation within the form could be pulled into the providers note via a SmartPhrase
Provided a hyperlink out to the PDMP website to perform a manual query
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Controlled Substance Monitoring
SmartForm Phase II: New Limits on
Prescription Opioids
Effective August 31, 2017, Ohio passed new limits for prescribing opioids for acute pain
SmartForm versatility allows additional documentation to the SmartForm already in use
With provider guidance, the SmartForm was expanded to accommodate documenting the
new limits and exceptions on prescription opioids
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Controlled Substance Monitoring
SmartForm Phase III: Appriss
Integration
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1. Link to Integration and
SmartForm.
2. Prior recorded SmartForm
Values
3. MEDD Equivalent Daily
Dose Calculations
4. Urine Drug Screenings
5. Scanned Med Contracts
6. Flags related to FYI flags
7. Links to PDMP websites
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Phase III: NarxCare Report
The NarxCare report is the report
display from Appriss
Takes the raw controlled
substance data received
from multiple state
pharmacies and creates
scores and graphs
Providers can quickly tell
the patient's history with
opioids and likelihood for
abuse
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Issue: Free Text Sigs
Solution: Require discrete sig for opioids
Over 104,600 free text
orders in early 2 years
window
Most can be
accommodated directly
with discrete frequency
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Issue: Free Text Sigs
Solution: Dose and Frequency Range
Education
Many providers were
unaware of ability to use
range doses on outpatient
prescriptions
Created four new discrete
frequency range choices:
Q3-4H PRN
Q4-6H PRN
Q6-8H PRN
Q8-12H PRN
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Add additional information to
patient sig
140 total sig character limit
Note to pharmacy
300 hard character limit
Issue: Free Text Sigs
Solution: Education of Conveying
Information to Pharmacy
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Concomitant Benzodiazepine &
Opioid Prescribing Highest Risk for
Overdose and Death
Actionable CDS for
Concomitant
Benzodiazepine & Opioid
Prescribing
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Concomitant Benzo/Opioids:
Analytics
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Pain Agreement Status in Order
Composer
Per CMS, starting in 2019, Pain Agreements will expire for an existing
controlled substance after 6 months.
When ordering a controlled substance, the pain agreement status will
display in the order composer.
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Release Note 635758
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Opioid Speed ButtonsDefault of 3
Days
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PDMP Review Information Available
on Radar Dashboards
Help track individual & organization compliance with state regulations from
prescription drug monitoring programs.
Show % of opioid prescriptions where providers didn't review PDMP
information in the same encounter.
Release Note 643819
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Contact information: Mabinstock@mercy.com
Please complete online session evaluation
Questions
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Appendix
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Gary Grazak, Integration Engineer
Jedediah Tuten, Director Pharmacy,
Acute Operations
Nicholas Waggamon, Application
Coordinator, Willow Pharmacist
Karen Goda, Application
Coordinator, Ambulatory
Anna Lendl, Application
Coordinator, Ambulatory
Michael Temple, Manager
CarePATH, Research Informatics
Marcus Hanna, Executive Director,
Emergency Services
Key Contributors
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Lisa Dubois, Application Coordinator,
Interfaces
Matt Rasmussen, Integration Engineer II,
Cloverleaf
Steve LeMaster, Application Coordinator,
Interfaces
Wayne Bohenek, Vice President, Care
Transformation
Brian Latham, Pharmacy Director, St.
Rita’s Medical Center
Rob Quigley, Vice President, CarePATH
Ambulatory
Kelley Recker, Vice President, CarePATH
Operations
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Our Numbers:
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Morphine Equivalents, cont.
Different opioids have different potencies, or Morphine
Equivalents (MEs):
Hydrocodone = 1
Oxycodone = 1.5
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Opioid Prescribing The Problem
There were 500,000 prescriptions a year out of CarePATH for
Vicodin 5-500/Norco 5-325
Each pill contains 5mg hydrocodone = 5.0 MEs
Typical every 4 hour dosing (6 pills/day) = 30 MEs/day
There were 500,000 prescriptions a year out of CarePATH for
Percocet 5 325
Each pill contains 5mg oxycodone = 7.5 MEs
Typical every 4 hour dosing (6 pills/day) = 45 MEs/day
These morphine equivalents were over the Ohio limit!
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Analytics Methodologies - Build
Key software used:
SQL server 2014
SQL Server Analysis Services 2016 RTM 1200
Visual Studio DTS 2015
Power BI v Oct 2015
Excel 2016 with Power Pivot
SSIS
Data sources used:
Epic (Clarity)
Explorys (IBM)
Kyruus
ACO Payors
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Acute Opioid
Working definition: No preceding opioid order in a 100
day window prior to the incident opioid order.
Measures not affected by erroneous or absent associated
diagnoses or problem list entries.
All of these metrics were built in a manner that is not
dependent on the use of an Epic registry.
They were set up in a way that was not dependent on, but
could leverage Epic’s method of calculating and storing
maximum morphine equivalent daily dose (MEDD)
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Diagnosis Requirement Association
Order Validation
Order Validation Point
Hard stop for diagnosis association
Lacks customization options
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Order validation lacks ability to report on firing rate trends and ability to measure success
of learned behavior
Less alerts over time by way of providers associating upstream
Created a robust tabular cube to monitor opioid prescribing overall allowed us to identify
an issue where some opioid orders were not requiring diagnosis
Data sharing moved Kentucky market to elect to participate in requirement
Diagnosis Requirement Association
Order Validation
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Actionable Alert: Special Consent (Ohio
HB 314)
Clinical Decision
Support (CDS) for
special consent form
for opioid prescribing
to minors
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Strategies to Decrease
Emergency Department Opioid
Use
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Emergency Department
Outpatient Opioid Prescription
Trend
“Opioid-Free” Emergency Department
Provider Outreach
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“Opioid-Free” Emergency Department:
Community and Patient Outreach
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“Opioid-Free” Emergency Department
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0%
5%
10%
15%
20%
25%
30%
Jan '14
Mar '14
May '14
Jul '14
Sep '14
Nov '14
Jan '15
Mar '15
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Jul '15
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Emergency Department Outpatient Opioid
Prescription Trend
Rate of Opioid Prescriptions to All Prescriptions
Springfield Market
Year Patient
Visits
Volume
Reduction
2014 80,916 -
2015 77,945 3.8%
2016 71,696 8%
2017 65,976 8%
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Strategies to Decrease
Inpatient Opioid Use
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Reducing Opioids in the Inpatient
Setting
As part of an organizational focus on decreasing overall numbers
of opioid prescriptions, the following inpatient opportunities were
identified:
Presence of narcotic pain relief options on admission order sets not
typically associated with pain
Lack of a collection of Alternatives to Opioids (ALTO) options in one
concise format for ease in ordering
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Designing a Solution:
Removing Pain Medications from Select
Order Sets
In reviewing all admission and focused order sets with IV and oral
pain medication, it was determined that over 30 were for treatment
of diagnoses not normally associated with pain
Validated with informatics committees and received nearly
unanimous support for removal of these pain medications
Standard biennial review cycle of all order sets still containing
pain medications will be assessed for clinical appropriateness
moving forward
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Designing a Solution:
Creating a Pain Management Focused
Order Set
To supplement the removal of pain medications from many admission
order sets and to provide a single location for opioid and non-opioid pain
treatment a Pain Management Focused Order Set was created
Plan to increase number of ALTO options after initial use period and
evaluation in conjunction with system Pharmacy and Therapeutics
Committee decisions
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Designing a Solution:
Creating a Pain Management Focused
Order Set
Key Features:
Non-customizable
Set as a suggested order set for all admitted patients
In addition to traditional acetaminophen and ibuprofen, added
additional ALTO options
Provider has to navigate through non-opioid options to get to
opioid choices
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Designing a Solution:
Creating a Pain Management Focused
Order Set
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SBIRT:
Screening, Brief Intervention, and
Referral to Treatment
Prior to SBIRT Implementation:
Alcohol, drug, and depression screenings were inconsistent
Alcohol and drug use screenings were outdated and not
linked to action
Approach to screening was inconsistent with public health
approach
There were no outcomes captured for patients’ drug or
alcohol use
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Screenshots: Prescreens
*All patients are asked the prescreen questions at triage
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SBIRT Screening Numbers (2016 - Q1
2018)
0
10000
20000
30000
40000
50000
60000
70000
80000
2016 2017 2018
Q1 Q2 Q3 Q4 YEARLY TOTAL
**The large, sustained spike in screenings beginning in Q2 2017 is due to the spread of SBIRT to several additional
sites at that time. Additional sites were added in Q1 2018, resulting in another large spike in screenings.
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SBIRT Outcomes - ROI
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Alcohol Use Illegal Drug Use
Number of Days (last 30 days)
Change in Substance Use for Mercy Patients 6 months post
SBIRT screening protocol (n=155)
Baseline
Follow-up
The chart illustrates change in number of days of substance use for Mercy patients with both a baseline and follow-
up interview (n=155). Mercy patients demonstrated statistically significant reductions in alcohol (p=.002) and illegal
drug use (p=.001). Data was collected from December 2015-August 2017
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Focused Order Set
Clinical Opiate Withdrawal
Scale (COWS)
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Background
Over the past few years, Mercy Health faced the rising tide of the
opioid crisis
Amid the increasing numbers of opioid-related overdoses and
deaths, a growing number of patients with an opioid use disorder
were presenting at Mercy inpatient facilities
There were few evidence-based, standardized tools to help guide
their treatment, and any existing tools were not integrated into the
EMR
Lack of ability to manage the symptoms of these patients while
admitted to our facilities complicated care
Increased burden of care on staff
Increased number of patients unable to complete necessary treatment
for co-morbidities
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Order Set Key Features
Presence of buprenorphine
Required approval by Mercy Health Formulary Committee for use in
order sets
Limited to 72 hour duration to make available to physicians without
special prescribing authority to exceed 72 hours
Combination of clonidine as adjunctive medication in linked panel
with both buprenorphine and tramadol as treatment options
Fixed dose strategy
COWS score dictated frequency of reassessment and follow-up doses
Avoided confusion of titrating various doses of medication
Availability of medications for symptom management
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Opiate Withdrawal Focused Order Set
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Designing a Solution:
Clinical Opiate Withdrawal Scale (COWS)
Nursing assessment that
evaluates 11 signs/symptoms
Stratifies severity of opiate
withdrawal
Flowsheet built to auto-
calculate score
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Outpatient Opioid Prescribing
Data Summary
-12%
-16%
-30%
-15
-50%
-20%
Significant Reductions in Opioid Prescribing Metrics
The following opioid ordering behaviors were substantially reduced
between December 2018 and December 2018:
Total Opioid
Orders
Opioid Orders to
All Medication
Orders
Opioids Orders
w/ MEDD > 80
Opioids w/ Day
Supply > 7 days
Total MEDD
per pt
Opioids
Orders w/
MEDD >30
Acute Pain
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Success Stories
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